The problem of medical resident work-hours has vexed medical educators for decades. The traditional model of sleep-deprived residents led to highly publicized medical mistakes, most famously the Libby Zion case in 1984.
Nobody wants tired doctors caring for them.
In response, various restrictions have been placed on how many hours medical residents are allowed to work. Since 2011, for instance, medical residents were no longer able to work for more than 16 hours at a time.
But like most regulations, the potential of unintended consequences can arise. I wrote in USA Today back in 2010 that shorter shifts hampered physician education and increased the number of patient handoffs between doctors, introducing new sources of error.
A recent study from JAMA Internal Medicine confirmed these fears:
Although the trainees working under the current work rules spent fewer hours at the hospital, they were not sleeping more on average than residents did prior to the rule change, and their risk of depression remained the same, at 20%, as it was among the doctors working prior to 2011 …
… “In the year before the new duty-hour rules took effect, 19.9% of the interns reported committing an error that harmed a patient, but this percentage went up to 23.3% after the new rules went into effect,” said study author Dr. Srijan Sen, a University of Michigan psychiatrist in a statement. “That’s a 15% to 20% increase in errors — a pretty dramatic uptick, especially when you consider that part of the reason these work-hour rules were put into place was to reduce errors.”
A damning implication from the study was that interns were expected to perform 24 hours worth of work in 16. This leads to a phenomenon known as “work compression” which can be another source of error.
Cash-strapped hospitals are partly to blame. There was never a question that shortening work-hours would cost money. Even back in 2010, the Institute of Medicine estimated that restricting work-hours would cost upwards of $1.7 billion. Hospitals did not hold up their end of the bargain by hiring additional workers that could off-load some of the non-educational work performed by medical interns.
There is a radical answer to this problem, and I’m not talking about going back to the old ways.
Extend medical residency by a year.
Surgical interns report that restricting work-hours impedes development of their surgical skills, and medical residents say they’re forced to miss teaching rounds because they went over their time allotment in the hospital. Another year of residency will better prepare these doctors for what awaits them after training.
And another class of residents will provide the much-needed help to solve staffing issues that arise from work restrictions.
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Of course, adding another year of residency is expensive. But no one said improving patient safety would be cheap.
Stop nibbling around the edges with varying iterations of capping work-hours. They have worsened patient safety and have done nothing to address the fatigue or mental health of medical trainees.
A dramatically different approach is needed to move this needle.
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